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Original Article

Survival rates of porcelain laminate restoration based on


different incisal preparation designs: An analysis
Ashish Shetty, Anjali Kaiwar, Shubhashini N, Ashwini P, Naveen DN, Adarsha MS, Mitha Shetty1, Meena N
Department of Conservative Dentistry, V. S. Dental College and Hospital, Bangalore, 1R.V. Dental College, Bangalore, K. P. Road, V.V.
Puram, Basavangudi, Bangalore, India

Abstract
Background: Veneer restorations provide a valid conservative alternative to complete coverage as they avoid aggressive
dental preparation; thus, maintaining tooth structure. Initially, laminates were placed on the unprepared tooth surface. Although
there is as yet no consensus as to whether or not teeth should be prepared for laminate veneers, currently, more conservative
preparations have been advocated. Because of their esthetic appeal, biocompatibility and adherence to the physiology of
minimal-invasive dentistry, porcelain laminate veneers have now become a restoration of choice. Currently, there is a lack
of clinical consensus regarding the type of design preferred for laminates. Widely varying survival rates and methods for its
estimation have been reported for porcelain veneers over approximately 210 years. Relatively few studies have been reported
in the literature that use survival estimates, which allow for valid study comparisons between the types of preparation designs
used. No survival analysis has been undertaken for the designs used. The purpose of this article is to attempt to review the
survival rates of veneers based on different incisal preparation designs from both clinical and non-clinical studies.
Aims and Objectives: The purpose of this study is to review both clinical and non-clinical studies to determine the survival
rates of veneers based on different incisal preparation designs. A further objective of the study is to understand which is the
most successful design in terms of preparation.
Materials and Methods: This study evaluated the existing literature survival rates of veneers based on incisal preparation
designs. The search strategy involved MEDLINE, BITTORRENT and other databases.
Statistical Analysis: Data were tabulated. Because of variability in the follow-up period in different studies, the follow-up
period was extrapolated to 10 years in common for all of them. Accordingly, the failure rate was then estimated and The
weighted mean was computed.
Conclusions: The study found that the window preparation was of the most conservative type. Incisal coverage was better
than no incisal coverage and, in incisal coverage, two predictable designs incisal overlap and butt were reported. In butt
preparation, no long-term follow-up studies have been performed as yet. In general, incisal overlap was preferred for healthy
normal tooth with sufficient thickness and incisal butt preparation was preferred for worn tooth and fractured teeth.
Keywords: Feather edge; preparation; survival rates; veneers; window Articles selected were both clinical and non-clinical studies

INTRODUCTION
Advancements in the field of adhesive dentistry and
porcelain technology have broadened the use of porcelain
veneer restorations significantly. These original fragile
restorations, introduced by Dr. Charles Pincuss in 1938,
have undergone considerable improvement and refinement
over the past few decades, and have now matured into
a predictable restorative concept in terms of longevity,
periodontal response and patient satisfaction.[1]
These veneer restorations provide a valid conservative
alternative to complete coverage as they avoid aggressive

dental preparation; thus, maintaining tooth structure.[2] Initially,


laminates where placed on the unprepared tooth surface.
Although there is as yet no consensus as to whether or
not teeth should be prepared for laminate veneers, currently,
more conservative preparations have been advocated.[3]
Because of their esthetic appeal, biocompatibility and
adherence to the physiology of minimal-invasive dentistry,
porcelain laminate veneers have now become a restoration
of choice to correct tooth forms, tooth position, close
diastemas, restore tooth fracture, erosions or mask tooth
discolorations.[4]
Access this article online

Address for correspondence:

Quick Response Code:

Dr. Ashish Shetty, V. S. Dental College and Hospital,


K. R. Road, V. V. Puram, Basavangudi, Bangalore 560004, India
E-mail: ashishshettyy@hotmail.com

Website:
www.jcd.org.in

Date of submission: 19.01.2010


Review completed: 12.05.2010
Date of acceptance: 11.08.2010

DOI:
10.4103/0972-0707.80723

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Journal of Conservative Dentistry | Jan-Mar 2011 | Vol 14 | Issue 1

Shetty, et al.: Survival rates of porcelain laminate restoration

Traditionally, a chamfer finish line is generally placed at


or close to the gingival margin and the enamel is reduced
by 0.30.5 mm, which enables the maintenance in enamel
strong bonding and, at the same time, sufficient thickness
of porcelain is maintained.[5,6] However, controversy exists
as whether to cover the incisal edge or not in these
preparations.
As a result, basically four types of incisal tooth preparations
have been advocated for veneers[7]:
1. Window (intraenamel), leaving an intact incisal enamel
edge.
2. Feather edge, leaving an incisal edge in enamel and
porcelain. Here, the veneer is taken up to the height of
the incisal edge but the edge is not reduced.
3. Beveled with incisal edge, entirely in porcelain. The
bucco-palatal bevel is prepared across the full width
of the preparation and there is some reduction of
the incisal length of the tooth and overlapped with
the porcelain extended into the palatal aspect of
the preparation as a chamfer. Proximally, contact
areas should also be maintained in case of minimum
preparations.
4. Incisal butt preparation is advocated for better
esthetics, stress distribution and positive seating.
The dynamics of an existing clinical situation broadly
influence the type of veneer design, the determining
factors usually being requisite for enhanced esthetics
(highly translucent incisal edge), the existing condition of
the incisal edge, the type of extension of the restoration to
be made and the stress distribution expected at the veneer
tooth interface.[8]
Further, more severe defects in the anterior dentition
require more extended preparation. In cases of severe
discolorations, fractured incisal angles, facial or proximal
caries or pre-existing restorations that need to be replaced,
an alternative preparation design must be attempted.[9] In
such cases, a deeper preparation with a proximal and palatal
extension is necessary to improve function and esthetics.
Currently, there is a lack of clinical consensus regarding
the type of design preferred for laminates. Widely varying
survival rates (48100%) and methods for estimating it have
been reported for porcelain veneers over approximately
210 years.[8]
Relatively few studies have been reported in the literature

that use survival estimates, which allow for valid study


comparisons between the types of preparation designs
used. No survival analysis has been undertaken for the
designs used.[8]
The purpose of this article is an attempt to review the
survival rates of veneers based on different preparation
designs from both clinical and non-clinical studies.

Aims and objectives


The purpose of this study is to review both clinical and nonclinical studies to determine the survival rates of veneers
based on different preparation designs. A further objective
of the study is to understand which is the most successful
design in terms of preparation.

MATERIALS AND METHODS


This study evaluated the existing literature survival
rates of veneers based on preparation designs. The search
strategy involved MEDLINE, BITTORRENT and other
databases. Keywords used were veneers and survival rates.
Articles selected were both clinical and non-clinical studies.
Aspects of the prep were quantified and analyzed from the
matter distilled from a review of these articles.

Statistical analysis
Data were tabulated. Because of variability in the followup period in different studies, the follow-up period was
extrapolated to 10 years in common foe all the studies.
Accordingly, the failure rate was then estimated and the
weighted mean was computed [Tables 16, Figure 1].

DISCUSSION
The demand for treatment of unesthetic teeth is steadily
growing. Accordingly, several treatment options have been
proposed to restore the esthetic appearance of teeth, like
full-coverage crowns and bonding with composites. While
full-coverage crowns is highly invasive and may have an
adverse effect on the pulp or periodontal tissue, bonding with
composites on the other hand, even though less invasive,
continues to remain susceptible to discoloration, wear and
marginal fractures.[6] The search for a better alternative led
to the development of porcelain laminate veneers. These
ultrathin ceramic restorations were reported to provide a
superior alternative to direct composite resin bonding for
esthetic modification of teeth.[27] Porcelain laminate veneers

Table 1: Percentage of failure rates of laminates with no preparation


Author
Sahini
Strassler and Weiner[11]
Calamia[12]
Strassler and Weiner[13]
[10]

No. of veneers
372
115
43
183

Porcelain

Adhesive

Failure rate (%)

Follow-up

Vitadur
Cerinate
Chameleon
Cerinate

Vita/Adh
Ultrabond
Ultrabond
Ultrabond

50
7
0
6

6.5 years
710 years
3 years
12190 months

Journal of Conservative Dentistry | Jan-Mar 2011 | Vol 14 | Issue 1

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Shetty, et al.: Survival rates of porcelain laminate restoration


Table 2: Percentage of failure rates of laminates with window preparation
Author

No. of veneers

Strassler and Natheson[14]


Kihnn[15]
Dunne and Miller[16]

291
59
315

Porcelain

Adhesive

Failure rate

Cerinate
Ultra bond
Ceramco cariologic/ceramco bonding Ceramco
96

Follow-up

1.7% #
1842 months
No failures
48 months
17% failed out of 32% 63 months

Table 3: Percentage of failure rates of laminates with feather edge


Author

No. of veneers

Porcelain

Adhesive

Failure rate

Follow-up
3 years
2 years
57 years
0.5 years
1.5 years
2.5 years
4 years

Christensen
Rucker[18]
Smales[8]
Chen[19]

163
44
64
546

Cerinate
Vitadur
Mirage/chameleon feldspathic
Cerinate

Ultrabond
Heliolink/vivadent
Ultrabond
Tenure

18%
0%
15%
1%

Jordan[20]

80

Den mat

Ultrabond

Christensen[17]
Nordbo[4]

165
135

Cerinate
Ceramco

Den mat resin cement


Procelite

3% failure, marginal
discrepancy 17%
13%
<3%*

[17]

3 years
3 years

Table 4: Percentage of failure rates of laminates with incisal overlap chamfer


Author

No. of veneers

Porcelain

Adhesive

Failure rate

Follow-up
56 years
17 years
23 years

Peumans
Jager[23]
Calamia[24]

87
80
72

Gc cosmotech
Mirage flc
Chameleon

Scotch bond-2
Mirage bond
Ultra bond

Gilmore[25]
Kihn[15]

200
59

Chameleon-terec
Ceramco cariologic

Aristidis,Dimitra[2]
Sieweke[26]
Magne[1]
Fradeni[3]

186
36
48
83

Ceramco
Ips empress
Kreation
Ips empress

Duo-core-terec
Ceramco cariologic
bonding system
Variolink
Duozem
Herculite
Syntac

7%
1%
4.1% #-failure rate
15%-marginal
discoloration
Not significant
2 failuers noted at
incisal edge
1.6%
24%
0%
1%

Porcelain

Adhesive

Failure rate

Follow-up

Gc cosmotech
Mirage flc
Chameleon

Scotch bond-2
Mirage bond
Ultra bond

7%
1%
4.1% #-failure
rate 15%-marginal
discoloration

56 years
17 years
23 years

[21,22]

130 months
48 months
5 years
16.5 years
4.5 years
16 years

Table 5: Percentage of failure rates of laminates with incisal bevel


Author

No. of veneers

Peumans[21,22]
Jager[23]
Calamia[24]

87
80
72

Table 6: Percentage of failure rates of laminates with analysis of data from non-clinical studies
Author

Year

Type of study

Type of preparation design


Window

Highton
Hui[29]
Magne[30]
Hann[5]
Castelnuovo[31]
Seymour[32]
Hekimogulu[12]
Zarone[33]
Stappert[34]
[28]

1987
1991
1999
2000
2000
2001
2004
2005
2005

Photoelastic
Stress
2D FEM
Stress
Stress
Stress
Microleakae
3D FEM
Stress

Incisal overlap

Butt margin

Feather edge

*
*
*
*
*
*
*
*
*

*Type of preparation

are now an accepted treatment modality. These restorations


offer a successful treatment that preserves tooth structure
while providing excellent esthetic results and patient

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acceptance.[3,6,18,21,27,35] The advantages of these restorations


are numerous and result from the combined advantages of
resins and porcelain.

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Shetty, et al.: Survival rates of porcelain laminate restoration

which basically comprises of a design where the veneer is


taken close to but not to the incisal edge.

Failure
10%

It is claimed that the window type of preparation may


withstand the highest load until failure.

Survival rate
90%

Figure 1: Survival rate and failure rate for incisal bevel preparation veneers. Common follow-up period of 10 years. The
total number of veneers was 114

Although the success of these restorations is now well


established, the survival of these restorations is influenced
by different variables.
Various studies on the survival rate of these restorations
exists. However, very few studies have actually focused on
the influence of preparation designs on the success rates
of these restorations. The current study makes an attempt
to review and establish a relationship between the survival
rate of these veneer restorations and preparation deigns
from the existing literature.
Traditionally, these veneer restorations were prepared
on unprepared tooth surface. However, currently,
conservative intraenamel preparations of 0.30.5 mm with
a chamfer gingivally are recommended. The difference
in preparation design comes with respect to the incisal
edge, with some clinicians advocating the preservation
of incisal edge while others prefer to overlap the incisal
edge.[4]
Thus, basically, regarding the laminate preparation, four
basic types of preparation have been described, namely the
window or intraenamel preparation, the feathered edge
preparation, incisal overlap and incisal bevel.
The veneer preparation design with no incisal coverage is
basically of three types:
1. Window preparation
2. Feather edge
3. No preparation
Analysis of the data obtained from clinical and non-clinical
studies revealed the following.

Window preparation
This preparation was suggested by Grabber and others,

In this study, the window-style preparation showed a


survival rate of almost 89%. Khin[15] reported no failures
with this type of preparation. Hui[29] showed that, using a
two-dimensional photoelastic stress analysis, this design
when prepared entirely in enamel withstood axial stress
most favourably. Further, it has been concluded that where
strength is an important requisite, the most conservative
type of veneer, namely the window preparation, was the
design of choice. An 11% failure rate was observed with
this design in this study. The common modes of failure
seen were interfacial staining (2%), debonding and minor
failures.[15] This preparation modality may produce a
weak enamel margin of poorly supported enamel prisms
that may undergo chipping on mandibular protrusion. A
majority of the failures occurred when the veneers where
placed on existing restorations. However, microleakage of
the window design at the incisal margin was less than that
in the overlap design.

Feather edge design/minimal preparation


design/facial preparation design
Here, the veneer is taken up to the height of the incisal
edge but the edge is not reduced, leaving an incisal edge in
enamel and porcelain.
Statistical analysis of the data obtained from clinical and
non-clinical studies showed a survival rate of 75% for this
type of design.
Christensen,[17] in his study, evaluated this design over a period
of 3 years and found an excellent marginal fit. He noticed
some discoloration at the end of 3 years and attributed it
to the low degradation of cement. Thirteen percent of the
cases had breakage over 3 years. It was observed that the
incisal area was the major location for porcelain fracture.
In lieu of this, Christensen recommends the modification
of the incisal area to reduce the fracture at the incisal area,
covering incisal with a butt joint, but cautions that there are
higher chances of wear opposing the tooth.
Smales,[8] on the other hand, in his observation showed a
survival rate of 85.5% but, in his study, this rate was less
compared with those that had incisal coverage (almost
96%). Bulk porcelain fractures were observed in this study,
where the incisal coverage was not performed. It was
concluded that a trend for better long-term survival was
noticed for teeth with incisal coverage Nordbo,[4] on the
other hand, analyzed that minimal porcelain restoration
with no incisal overlapping was conservative, predictable
and successful. Wrap-over method should be avoided

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Shetty, et al.: Survival rates of porcelain laminate restoration

in young teeth as it was less conservative. Further, he


cited that the bond strength of etched porcelain is 1428
mpa, which surpasses the cohesive strength of porcelain.
Further, porcelain should be prevented from direct stress.
In clinical situations with normal overbite, this design is to
be preferred.
Jordon,[20] in his study, showed a high survival or retention
rate of 97% when veneers were seated with the feather edge
design. He attributes this excellent survival rate to a double
micromechanical lock that is between the etched tooth
surface and the etched porcelain surface. Compared with
window preparation, the feather edge preparation will not
produce a weak margin of unsupported enamel prisms that
may undergo chipping on mandibular protrusion. In the
window prep, the adhesive cement will be bonded to the
longitudinal aspects of the incisal enamel prisms, leading
to a weaker bond. However, he cautions that there may be
wear of the luting agent at the incisal margin, to the order
of 100 m with the feather edge design.
Meijering,[36] In his study of the feather edge design,
showed a survival rate of 75%. The common modes of
failure noticed were chipping of incisal porcelain, chipping
of incisal enamel and incisal wear.

No preparation
Here, the veneer is directly bonded on to the unprepared
tooth surface.
Statistical analysis of the data available revealed a high
failure rate of 56% with this design. The common modes
of failure seen were debonding and fracture. Lack of tooth
preparation was one of the major factors for high failure
rates of 56%.[10]
The reason attributed for this was that stress concentration
is less intense within restoration fitted to the prepared
teeth.[28,37] Further, surface preparation increases the bond
strength as it increases the surface area and removes the
aprismatic layer that is resistant to acid etching. Also,
preparing the tooth helps for a positive seat. Bonding allows
restoration to act as an integral part of the tooth structure.
The intimate contact allows better stress distribution and
prevents local overloading of brittle material. Factors that
influence the bond may effect the long-term and shortterm survival rates.[16]

Veneer preparation designs with incisal


coverage
Although Meijering[36] found no difference between
coverage and no incisal coverage, greater survival rate
for incisal coverage (almost 96%) was noticed by Smales[8]
compared with no incisal coverage (85%).
Rucker[18] found that better long-term survival rates was

14

noticed for teeth with incisal coverage.


Incisal coverage designs are of two types:
Incisal overlap.
Incisal bevel or butt joint.
Incisal overlap: Statistical analysis of the data revealed a
high survival rate of 93% with this design. The good survival
rate was attributed to better stress distribution.
Common modes of failure seen were failure of adhesive
bond, increased marginal defects noticed in the palato
incisal area and higher % of microleakage noticed at the
palatoincisal area.
Highton et al. found that with the incisal overlap design,
during protrusive movement, a wider area of tooth
structure is involved in stress distribution.[28]
Further, this design increases the mechanical resistance
to fracture. In addition, it provides superior intrinsic
resistance to porcelain.[28,30,33]
When compared with the window preparation, in terms
of microleakage, the incisal overlap design showed more
microleakage. This can be attributed to the shrinkage of
porcelain by the firing process veneers may contract
from the margins leading to marginal gap formation at the
linguoincisal edge.[3]
Incisal butt: No long-term studies are present with respect
to this design. Statistical analysis of the data available
showed a survival rate of 90%.
This design is advocated for better esthetics, stress
distribution and positive seating. Stress analysis of load
distribution studies showed that the butt design showed
the strongest fracture resistance.[1,30,31]
When compared with the incisal overlap design, it was
seen that light chamfer exhibits higher tensile stress
because it extends closer to the palatal concavity. This is
more problematic in a deeper concavity extending to the
incisal edge as it is seen in severely worn teeth. Therefore,
in such cases, a butt margin is preferred.
In the presence of maximum tooth structure, the stress
pattern on the palatal surface is barely influenced by the type
of finish line. Here, butt or mini chamfer may be preferred.
Chamfer extending into the concavity is not recommended.
Elevated stress is generated in the palatal concavity during
functional loading and, therefore, mini chamfer should be
replaced by a simpler design such as butt.
This provides the margin with a strong bulk of porcelain.
Crack propensity of porcelain veneers can be minimized by

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Shetty, et al.: Survival rates of porcelain laminate restoration

sufficient thickness of the ceramic material combined with


a minimal thickness of composite.[30]
The advantages of incisal butt preparation are that a flat
incisal wall and incisal reduction give desirable character
of the veneer at the incisal third.

12.
13.
14.
15.

Further, there is preservation of the peripheral enamel


layer. The butt joint design provides a favourable ceramic/
luting ratio and reduces the risk of post-insertion cracks
due to shrinkage.[19,38,39]

16.

The clinical advantages of such a design are:


a. With incisal butt, joint results in stronger restoration.
b. Simplified tooth preparation tech.
c. Eliminates the risk of thin, unsupported palatal ceramic
ledges.
d. Impressions produce cast with clear finish lines.

19.

CONCLUSIONS

REFERENCES

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

18.

20.
21.
22.
23.

The authors made the following conclusions based on the


results of the following study:
Window preparation the most conservative type.
Incisal coverage better than no incisal coverage.
In incisal coverage, two predictable designs exist,
incisal overlap and butt.
In butt preparation, no long-term follow-up studies
have been performed as yet.
Incisal overlap preferred for healthy normal tooth with
sufficient thickness.
Incisal butt preparation preferred for worn tooth and
fractured teeth.

1.

17.

24.
25.
26.
27.
28.
29.
30.
31.
32.

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Source of Support: Nil, Conflict of Interest: None declared.

Journal of Conservative Dentistry | Jan-Mar 2011 | Vol 14 | Issue 1

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